Health Assessment Questionnaire - Simply Great Health, Naturopaths, Natural Therapists, Auckland

Please complete this form at least 48 hours before your first appointment to help us gain an understanding of how we can help.

Personal Details

Name*

Prefix First Last

Date of Birth*

Contact Details

Address*

Street Address Suburb City Post Code Country

Phone*

Mobile*

Email*

Medical Details

Reason for attending clinic?*

Do you have any other existing medical conditions?*

Medications

What medications are you taking?*

Have you tried any other therapies for this condition?*

What supplements/herbs are you taking?*

Do you have any known allergies? Please list*

Do any of your other family members have similar health conditions?*

Digestive Health

Please indicate if you experience any of the following on a scale of 1 – 4 with
1 being never,
2 being occasionally,
3 being frequently and
4 being daily

Diarrhoea*

Constipation*

Alternating constipation and diarrhoea*

Feelings of bloating*

Craving sweet foods in the afternoon*

General low energy*

Low energy in the afternoon only*

Comment

Phone

This field is for validation purposes and should be left unchanged.

Please bring any recent medical test results with you.

Attached to this questionnaire is a 1 week food diary. Please DOWNLOAD it and bring it with you to your consultation. Please complete it honestly using a typical week.
NO judgements are being made but it is useful to indicate possible nutrient deficiencies.

Thank you for completing this form and we look forward to seeing you at your appointment.

DOWNLOAD FOOD DIARY

Ph 09 444 4527

Personal Details

Contact Details

Medical Details

Medications

Digestive Health